A Comparison of Outcomes following Plate versus Pin Fixation of Metacarpal Shaft and Neck Fractures.

The aim of this study is to compare clinical and radiographic outcomes of open reduction and internal fixation versus closed reduction and percutaneous pinning of metacarpal fractures in relation to anatomic and surgical variables. Methods: Electronic medical records at two institutions were reviewed for patients who underwent surgical intervention for metacarpal fractures. Data were collected from those who underwent reduction and internal fixation with either plates or Kirschner wires (K-wires). Inclusion criteria included minimum postoperative follow-up of 60 days and age 18 years or older. Exclusion criteria included insufficient radiographic data, previously attempted closed reduction with immobilization, pathologic fracture mechanism, history of previous trauma or surgery to the affected bone, and fixation technique other than plate or K-wire. Results: We reviewed data for patients treated over a 22-year time period. Ultimately, 81 metacarpal shaft and neck fractures in 60 patients met inclusion criteria. Among all metacarpal fractures, complications were present in 39 (48.1%) cases. There were no significant associations between complication prevalence and hardware type. Revision surgery was required in 11 (13.6%) patients; there were no significant associations between revision procedures and hardware type. Postoperatively, all patients with imaging data had radiograph follow-up to assess union status. There was no significant association between time to union and hardware type. Conclusions: Outcomes showed no significant difference between plate and pin fixation for metacarpal shaft and neck fractures. These findings suggest that surgeons may have flexibility to decide on the type of operative intervention while considering patient-specific factors, such as the need for early mobilization.

Single Incision, Dual Window Approach for a Comminuted Distal Radius Fracture.

Introduction Complex distal radius fractures often involve a fragment of the volar-ulnar articular surface and the radial styloid. The volar ulnar corner of the distal radius is an important constraint to volar translation of the carpus and thus requires stable fixation to prevent wrist displacement. The traditional volar Henry approach often requires undue tension on the median nerve while retracting for access to the ulnar aspect of the radius. To protect the median nerve from iatrogenic injury and to improve exposure of the surgical site, we propose a single incision, dual window approach to the distal radius for complex bi-columnar fractures. Methods This technique combines the trans-Flexor Carpi Radialis (FCR) approach with a subcutaneous dissection to the ulnar aspect of the wrist. This window utilizes the interval between the ulnar neurovascular bundle and the carpal tunnel contents. Results This technique allows the surgeon to work through either window and thus visualize and directly fixate the various fracture fragments. We have treated complex articular distal radius fractures associated with ulnar communition with this novel technique and it has provided direct reduction with improved fragment access. The surgical technique, a case presentation and results are detailed in this report. Conclusion This case report has demonstrated that complex bi-columnar fractures of the distal radius can be effectively approached and fixated with a single incision dual window approach.

Vacuum-Assisted Therapy for Combined Volar-Dorsal Soft-Tissue Defects of the Hand: A Case Report.

ABSTRACT: Application of negative-pressure wound therapy dressings to the web spaces and small, often moist, areas of the hand can be technically demanding and time consuming. The researchers present a case report and technique for managing a devastating hand infection and soft-tissue defects by creating a self-fabricated sponge glove that is easily reproducible. Vacuum-assisted therapy for combined volar dorsal soft-tissue defects of the hand, or "Hand Vac," is a novel approach for treating extensive hand wounds. This technique was used in a patient with diabetes with a deep space infection of the hand following serial debridements and antibiotic bead therapy. A single, medium-size sponge was cut using a knife and scissors to create an easily applied glove that was then sealed with adhesive dressing and a single suction port. The patient avoided complete amputation of the hand and deep infection was eradicated. The wounds had progressive granulation and healing and were eventually covered with split-thickness skin grafts. The authors conclude that severe soft-tissue defects involving both the volar and dorsal aspects of the hand can be effectively managed with a single glove-like sponge and suction port.

Treatment for Acute Proximal Interphalangeal Joint Fractures and Fracture-Dislocations: A Systematic Review of the Literature.

Proximal interphalangeal joint (PIPJ) fractures and fracture-dislocations are common hand injuries and recognition of this injury pattern is essential in the management of these fractures. Although a variety of treatment options have been reported in the literature, the optimal treatment remains controversial. MEDLINE, EMBASE, and The Cochrane Library Database were screened for treatment strategies of PIPJ fracture and fracture-dislocation. Demographic data and outcome data were collected and recorded. A total of 37 studies including 471 patients and 480 fingers were reviewed. PIPJ range of motion (ROM) was greatest postoperatively in patients who underwent volar plate arthroplasty at 90.6 degrees. Dynamic external fixation resulted in the lowest PIP joint ROM with an average of 79.7 degrees. Recurrent pain and osteoarthritis were most often reported in extension block pinning at 38.5 and 46.2%, respectively. Open reduction and internal fixation had the highest rate of revision at 19.7%. Overall, the outcomes of PIP fractures and fracture-dislocations are based on the severity of injury, and the necessary treatment required. Closed reduction with percutaneous pinning and volar plate arthroplasty had good clinical and functional outcomes, with the lowest complication rates. Hemi-hamate arthroplasty and dynamic external fixation were utilized in more complex injuries and resulted in the lowest PIPJ ROM. This is a therapeutic, Level III study.

Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures.

Background: Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. Methods: Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. Results: Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate (P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion (P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. Conclusions: The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.

Factors Affecting Operative Duration in Isolated Open Carpal Tunnel Release.

Background Open carpal tunnel release (CTR) is one of the most commonly performed operative procedures with operative duration being a primary metric of operating room efficiency. The purpose of this study was to identify factors associated with prolonged operative duration, in performing CTR. Materials and Methods CTR cases performed by a single surgeon from September 2013 to October 2015 were reviewed. Patient age at the time of surgery, sex, location of surgery (specialty orthopaedic hospital versus ambulatory surgery center), body mass index (BMI), American Society of Anesthesiologists classification, total operative duration (TOD), and procedure time (PT) were recorded. Obesity was defined as BMI > 30 and morbid obesity was defined as BMI > 35. Data were analyzed to identify factors associated with prolonged TOD or PT. Results One hundred and nine consecutive patients underwent isolated CTR. Mean age at time of surgery was 62 years (range: 24-92 years). Nonobese patients were found to have significantly shorter TOD than obese patients (22.3 vs. 24.4 minutes). Similarly, patients who were not morbidly obese had significantly shorter TOD than morbidly obese patients (22.6 vs. 26 minutes). No other factors were associated with prolonged TOD. No difference in PT was found between normal weight, obese, and morbidly obese groups. Conclusions TOD, but not procedure time, is significantly affected by obesity. Our findings are relevant when scheduling and preparing obese patients for surgery, which may have a significant impact on health resource utilization. Level of Evidence This is a Level III, economic/decision analysis study.

Analysis of Expected Costs of Carpal Tunnel Syndrome Treatment Strategies.

BACKGROUND: Over 500 000 carpal tunnel releases costing over $2 billion are performed each year in the United States. The study's purpose is to perform a cost-minimizing analysis to identify the least costly strategy for carpal tunnel syndrome treatment utilizing existing success rates based on previously reported literature. METHODS: We evaluate the expected cost of various treatment strategies based on the likelihood of further treatments: (1) a single steroid injection followed by surgical release; (2) up to 2 steroid injections before surgical release; (3) 3 steroid injections before surgery, and (4) immediate surgical release. To reflect costs, we use our institution's billing charges to private payers and reimbursements from Medicare. A range of expected steroid injection success rates are employed based on previously published literature. RESULTS: Immediate surgical release is the costliest treatment with an expected cost of $2149 to $9927 per patient. For immediate surgical release to cost less than a single injection attempt, the probability of surgery after injection would need to exceed 80% in the Medicare reimbursement model and 87% in the institutional billing model. A single steroid injection with subsequent surgery, if needed, amounts to a direct cost savings of $359 million annually compared with immediate surgical release. Three injections before surgery, with "high" expected success rates, represent the cost-minimizing scenario. CONCLUSIONS: Although many factors must be considered when deciding upon treatment for carpal tunnel syndrome, direct payer cost is an important component, and the initial management with steroid injections minimizes these direct payer costs.

Trends and Demographics in the Utilization of Total Wrist Arthroplasty.

BACKGROUND: Health disparities exist among many patient populations, with race, payer status, hospital size and access to teaching versus non-teaching hospitals potentially affecting whether certain patients have access to the benefits of total wrist arthroplasty (TWA). METHODS: The National Inpatient Sample Database (NIS) was queried from 2001 to 2013 for TWA using the ICD-9 code 81.73. Patient-level data included age, sex, race, payer status, and year of discharge. Hospital-level data included hospital bed size, location, teaching status, and region. RESULTS: There were 1,213 patients identified who underwent TWA between 2001 and 2013. Total number of procedures decreased from 88 TWAs in 2001 to 65 in 2013. The yearly volume ranged from 33 in 2005 to 128 in 2007. The male-female ratio was 2.5 to 1. The majority of TWA procedures were performed at urban teaching hospitals (60.8%). CONCLUSIONS: The NIS database shows a downward trend of total wrist arthroplasty utilization. The majority of total wrist arthroplasties were performed at urban teaching hospitals indicating treatment occurs most often at academic centers of excellence.

Crossed K-Wires Versus Intramedullary Headless Screw Fixation of Unstable Metacarpal Neck Fractures: A Biomechanical Study.

Background: Intramedullary headless screw (IMHS) has shown promise as an alternative to other fixation devices for metacarpal neck fractures. The purpose of this study was to assess the biomechanical performance of IMHS versus the commonly-used crossed K-wire technique. We hypothesized that IMHS fixation provides superior stability to K-wires. Methods: A metacarpal neck fracture model in 23 human cadaveric metacarpals was created. The specimens were divided into two groups based upon fixation method: Group 1, 3 mm intramedullary headless screw; and Group 2, 0.045 inch crossed K-wires. A cantilever bending model was used to assess load-to-failure (LTF), maximum displacement, energy absorption, and stiffness. Results: The mean LTF was 70.6 ± 30.1 N for IMHS and 97.5 ± 34.7 N for crossed K-wires. Mean stiffness was 11.3 ± 3.4 N/mm and 17.7 ± 7.8 N/mm for IMHS and crossed K-wires, respectively. The mean maximum displacement was 20.2 ± 4.6 mm for IMHS and 24.1 ± 3.7 mm for crossed K-wires. Moreover, mean energy absorption was 778.3 ± 528.9 Nmm and 1095.9 ± 454.4 Nmm, respectively, for IMHS and crossed K-wires. Crossed K-wires demonstrated significantly higher stiffness and maximum displacement than IMHS (p < 0.05). Conclusions: IMHS fixation of unstable metacarpal neck fractures offers less stability compared to crossed K-wires when loaded in bending. Clinical Relevance: Crossed K-wires offer superior stability for the treatment of metacarpal neck fractures. These results reveal that IMHS fixation is less favorable biomechanically and should be cautiously selected with regards to fracture stability.

Radial Shaft Convergence in Distal Radius Fractures: Diagnosis and Treatment.

Radial shaft convergence in distal radius fractures is often misdiagnosed. This common deformation is often associated with a radial translation of the distal fragment. This parameter has to be corrected because of the increased risk of distal radioulnar joint instability due to detensioning of the distal interosseous membrane if there is an associated triangular fibrocartilage complex lesion. A new radiologic sign for diagnosis of proximal radius convergence during distal radius fracture is presented as well as technical tips for correction of this deformity.

Flexor Tendon Injuries.

Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

Orthopedic Oncology Caseload Among Orthopedic Surgery Residents.

Despite educational focus regarding orthopedic oncology during residency, assessment of resident orthopedic oncology caseload has not been performed. The purpose of this study was to evaluate orthopedic oncology caseload trends and variation among residents. The Accreditation Council for Graduate Medical Education case log reports for orthopedic surgery residents were reviewed for graduating years 2007 to 2013. Trends in orthopedic oncology cases and variation in the median number of cases performed by residents in the 90th, 50th, and 10th percentiles of caseload were evaluated. The proportion of orthopedic oncology caseload among all cases performed by residents increased significantly (P = 0.005) from 2007 to 2013. Likewise, the mean number of adult (P = 0.002), pediatric (P = 0.003), and total orthopedic oncology cases increased significantly (P = 0.002). On average, residents in the 90th, 50th, and 10th percentiles performed 83, 28, and 3 cases, respectively. The current study demonstrates a significant increase in adult, pediatric, and total orthopedic oncology caseload. There is also evidence of substantial caseload variation among residents. Caseload variation may influence the education and technical proficiency of orthopedic residents.

Performance Outcomes After Hook of Hamate Fractures in Major League Baseball Players.

CONTEXT: Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players' future athletic performance. OBJECTIVE: To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. DESIGN: Retrospective case-control design. SETTING: Retrospective database study. PARTICIPANTS: 18 MLB players who sustained hook of hamate fractures. METHODS: Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989-2014) were obtained from injury reports, press releases, and player profiles ( www.mlb.com and www.baseballreference.com ). Player age, position, number of years in the league, mechanism of injury, and treatment were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury for the main performance variable-Wins Above Replacement-were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. MAIN OUTCOME MEASURES: Postinjury performance compared with preinjury performance and matched-controls. RESULTS: Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in Wins Above Replacement or isolated power when preinjury and postinjury performance were compared. When compared with matched-controls, no significant decline in performance in Wins Above Replacement the first season and second season after injury was found. CONCLUSION: MLB players sustaining hook of hamate fractures can reasonably expect to return to their preinjury performance levels following operative treatment.

Assessment of Forearm Rotational Control Using 4 Upper Extremity Immobilization Constructs.

BACKGROUND: Forearm immobilization techniques are commonly used to manage distal radius, scaphoid, and metacarpal fractures. The purpose of our study was to compare the degree of rotational immobilization provided by a sugar-tong splint (STS), short arm cast (SAC), Munster cast (MC), and long arm cast (LAC) at the level of the distal radioulnar joint (DRUJ), carpus, and metacarpals. METHODS: Seven cadaveric upper extremity specimens were mounted to a custom jig with the ulnohumeral joint fixated in 90° of flexion. Supination and pronation were unrestricted. K-wires were placed in the distal radius, scaphoid, and metacarpals using fluoroscopic guidance to measure the total arc of rotation referenced to the ulnar ex-fix pin. Baseline measurements followed by sequential immobilization with well-molded STS, SAC, MC, and LAC were obtained with 1.25, 2.5, and 3.75 ft-lb of supination and pronation force directed through the metacarpal K-wire. Each condition was tested 3 times. Digital photographs were taken perpendicular to the ulnar axis to analyze the total arc of motion. RESULTS: The most effective constructs from least to greatest allowed rotational arcs were LAC, MC, SAC, and STS. Above-elbow constructs (MC, LAC) demonstrated superior immobilization compared with below-elbow constructs (SAC) ( P < .001). Circumferential constructs (SAC, MC, LAC) were superior to the noncircumferential construct (STS) ( P < .001). There were no significant differences between the MC and LAC in all conditions tested. CONCLUSIONS: Both circumferential and proximally extended immobilization independently improved rotational control of the wrist. However, extending immobilization proximal to the epicondyles did not confer additional stability.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

Distal Radius Fractures: Reconstruction Approaches, Planning, and Principles.

Distal radius fracture (DRF) is a common injury. Treatment options have evolved and now several can be used to address even the most complex fracture patterns. Complex fractures of the distal radius and ulna can be challenging, and specific goals must be kept in mind to achieve definitive anatomical and functional restoration. This article summarizes the concepts, principles, and surgical options regarding complex DRF reconstruction.

Information on Orthopedic Trauma Fellowships: Online Accessibility and Content.

The internet is a popular resource for orthopedic fellowship applicants. We conducted a study to assess the accessibility of orthopedic trauma fellowship (OTF) program websites and to evaluate the content on the sites. We queried the online database of the Orthopaedic Trauma Association (OTA) and the online Fellowship and Residency Electronic Interactive Database (FREIDA) to assess available OTF program links. We used Google to assess how accessible the sites are from outside the databases. We then analyzed accessible sites for content pertinent to OTF applicants. Of the 49 OTF programs identified, 42 (86%) had their websites accessible from Google and FREIDA links. The OTA database had no OTF website links. Analysis of the 42 accessible OTF sites revealed they had an average of 40% (range, 0%-75%) of assessed content, with operative experience on 88% of sites and a program description on 93% of sites. OTF programs with >1 fellow had significantly more education content (48% vs 33%; P = .043) and total content (46% vs 37%; P = .01) on their sites than OTF programs with 1 fellow. Accessibility and content of OTF websites are highly variable and largely deficient. OTF programs should focus on improving their website accessibility and content.

Microsurgery Case Volume During Orthopedic Surgery Residency: A 7-Year Assessment.

BACKGROUND: Microsurgery is a specialized surgical technique with wide clinical application. The purpose of this study was to analyze case logs of graduating orthopedic surgery residents to assess trends in case volume for microsurgery procedures. METHODS: Accreditation Council for Graduate Medical Education case log reports were analyzed for microsurgery experience from 2007 to 2013. The mean number of adult, pediatric, and total microsurgery cases was noted. In addition, the median number of microsurgery procedures performed by the 90th, 50th, and 10th percentiles of residents (by case volume) was recorded. Temporal changes in case volume were calculated utilizing linear regression analyses. RESULTS: The proportion of microsurgery procedures increased significantly (1.3% to 2%; P = .024). The mean number of adult (24.5 to 41.9; P = .01), pediatric (1.9 to 3.4; P = .011), and total (26.3 to 45.3; P = .01) microsurgery procedures also increased significantly. Similarly, residents in both the 90th (63 to 109; P = .01) and 50th (10 to 21; P = .036) percentiles sustained significant increases in the median number of microsurgery procedures. No change was noted for residents in 10th percentile (0 to 0; P > .999). Graduating residents in the 90th percentile performed over 6 times more microsurgery procedures than residents in the 50th percentile. CONCLUSIONS: Microsurgical caseload is increasing among graduating orthopedic residents. However, there is substantial variability in resident microsurgery case volume. Future investigations are needed to explore the educational implications of these findings and should seek to correlate microsurgical caseload with competency.

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study.

BACKGROUND: We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon-splitting approach, a dorsal extensor tendon-reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach. METHODS: The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen. RESULTS: The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens. CONCLUSIONS: Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey.

PURPOSE: Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection. METHODS: We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed. RESULTS: For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%). CONCLUSIONS: Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analyses I.